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Acute asthma exacerbations in children: Emergency department management

Author
Richard J Scarfone, MD, FAAP
Section Editors
Robert A Wood, MD
Gregory Redding, MD
Deputy Editor
Elizabeth TePas, MD, MS
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2014. | This topic last updated: Mar 25, 2014.
INTRODUCTION Clinical decision-making in the management of the child with an acute asthma exacerbation
includes the following questions:
How sick is the child?
Which drugs should be used for treatment?
What are the optimal doses and delivery routes?
When is more aggressive management necessary?
The approach to the outpatient management of the child with an acute asthma exacerbation is presented below.
Rescue medications for acute symptoms and inpatient management of asthma exacerbations in children are
discussed in detail separately. (See "Acute asthma exacerbations in children: Inpatient management" and "Acute
severe asthma exacerbations in children: Intensive care unit management" and "Asthma in children younger than 12
years: Rescue treatment for acute symptoms".)
The management of acute asthma exacerbations in adults is also discussed separately. (See "Treatment of acute
exacerbations of asthma in adults".)
OVERVIEW OF TREATMENT The approach to the management of acute asthma exacerbations described below
is geared toward management in the emergency department (ED). Initial treatment (beta-agonist therapy and oral
glucocorticoids) is sometimes provided in the primary care setting or even at home [1]. However, children with
moderate to severe exacerbations require close observation for clinical deterioration, frequent treatments, and
repeated evaluation. Thus, most children with moderate or severe asthma exacerbations should be managed in an ED
setting. (See "Acute asthma exacerbations in children: Home/office management and severity assessment".)
We used the Pulmonary Index Score (PIS) (table 1) to determine the initial severity of the exacerbation and level of
treatment needed (ie, mild, moderate, or severe) [2]. Other scores are available and are reviewed separately.
Goals The goals of therapy for an acute asthma exacerbation include [1]:
Rapid reversal of airflow obstruction by repeated administration of inhaled bronchodilators and early institution
of systemic glucocorticoids. (See 'Pharmacotherapy' below.)
Correction of hypoxemia and/or severe hypercapnia, if present; hypoxemia is alleviated by administration of
supplemental oxygen as necessary; hypercapnia usually improves with reversal of airflow obstruction.
(See 'Oxygen therapy'below and 'Pharmacotherapy' below.)
Reduction of likelihood of recurrence by intensifying baseline therapy. (See 'Discharge meds' below.)
General approach The general approach to treatment of an acute asthma exacerbation includes administration of
inhaled bronchodilators (eg, albuterol), as well as antiinflammatory agents (ie, glucocorticoids) in most patients
(algorithm 1and algorithm 2). Supportive care for children with acute asthma exacerbations includes administration of
supplemental oxygen and fluids as necessary and frequent monitoring of response to therapy.
Medications Inhaled, short-acting, selective beta-2 adrenergic agonists (beta agonists or SABA) are the mainstay
of emergent treatment of acute asthma exacerbations. For children with mild exacerbations, systemic glucocorticoids
are usually added if the symptoms and signs of airway obstruction fail to resolve after the first treatment with inhaled
beta agonists. Children with moderate or severe exacerbations should receive systemic glucocorticoids as soon as
possible. Additional pharmacotherapeutic agents that may be indicated in children with moderate or severe asthma
include nebulized ipratropium bromide, intravenous magnesium sulfate, and parenteral beta agonists.
Oxygen therapy Many patients with moderate to severe acute asthma exacerbations have hypoxemia as a result
of ventilation-perfusion (V/Q) mismatch, although in most patients the hypoxemia is mild and does not require
treatment with supplemental oxygen. Beta agonists may worsen this mismatch by causing pulmonary vasodilation in
areas of the lung that are poorly ventilated. Humidified oxygen should be provided as needed to maintain an oxygen
saturation of 92 percent [3]. All nebulized medications should also be delivered with oxygen, generally at a flow rate
of 6 to 8 L/min. (See "Continuous oxygen delivery systems for infants, children, and adults".)
Monitoring The clinical status of children who are being treated for acute asthma should be monitored frequently.
Ongoing monitoring of respiratory rate, heart rate, oxygen saturation, degree of alertness, accessory muscle use, and
retractions is crucial to decisions regarding treatment and disposition [4].The frequency of monitoring varies
depending upon the severity of illness and response to initial therapy, but for most patients is typicall y every 20 to 30
minutes for the first hour of therapy. Patients who require continuous nebulizer therapy continue to be monitored every
20 to 30 minutes. Clinicians may also find it helpful to measure peak expiratory flow rate (PEFR). However,
assessment of PEFR may have limited utility in the assessment of sicker or younger children. It is optimal if the child
can make three attempts while standing (the best score is used) and is most useful when it can be compared with the
child's known personal best score.
Arterial blood gas It is rarely necessary to obtain arterial blood gas (ABG) samples in children with acute asthma.
Oxyhemoglobin saturation can be assessed with pulse oximetry.
Many severely ill children have hypercapnia on arrival to ED, but this usually improves after therapy. In children who
require admission to the intensive care unit (ICU), measurement of PaCO
2
via ABG after a clinical plateau has been
reached provides an objective measure of disease severity. In moderately or severely ill children, ABG's obtained
before aggressive intervention often are abnormal, but rarely affect management. (See "Acute severe asthma
exacerbations in children: Intensive care unit management".)
Chest radiograph Chest radiographs (CXRs) rarely provide information that alters the management of children
with acute asthma exacerbation [5,6]. Viral upper respiratory tract infections are the most common trigger for
wheezing in children and the presence of low grade fever in children with acute asthma exacerbation often prompts
clinicians to obtain CXRs to exclude pneumonia. However, the rate of specific CXR findings in this setting is extremely
low, except in the presence of focal examination findings (eg, crackles or decreased breath sounds), fever (>39C), or
severe disease [5,7]. Consider obtaining CXRs to rule out pneumonia, atelectasis, and air leak if there are focal
examination findings (eg, crackles or decreased breath sounds), fever (>39C), severe disease, uncertainty about the
diagnosis, or tachypnea, hypoxemia, or chest pain that are present after initial therapy has been given.
Mild exacerbation For children with mild asthma exacerbation (PIS <7, (table 1)), we suggest the following:
Albuterol inhalation therapy administered via small volume nebulizer (SVN) at a dose of 0.15 mg/kg (minimum
2.5 mg and maximum 5 mg per dose) or metered-dose inhaler (MDI-S) at a dose of one-quarter to one-
third puff/kg (minimum two puffs and maximum eight puffs per dose). If repeated doses are needed, they should
be given every 20 to 30 minutes for three doses [1]. (See 'Dosing and administration' below.)
Patients who do not respond after three doses should be reassessed and treated accordingly (algorithm 1).
Discharge criteria for patients who do respond to therapy are reviewed below. (See 'Moderate
exacerbation' below and 'Severe exacerbation' below and 'Discharge to home' below.)
Administration of systemic glucocorticoids to those who fail to improve after one inhalation therapy (table 2).
(See 'Systemic glucocorticoids' below.)
Moderate exacerbation For children with moderate asthma exacerbation (PIS 7 to 11, (table 1)), we suggest the
following approach (algorithm 1):
Administration of supplemental oxygen if oxygen saturation 92 percent in room air. (See 'Oxygen
therapy' above.)
Albuterol nebulization (0.15 mg/kg, maximum 5 mg) combined with ipratropium bromide (250 microgram/dose if
<20 kg; 500 microgram/dose if >20 kg) every 20 to 30 minutes for three doses or continuously.
Many studies show comparable outcomes for patients who receive albuterol via SVN or MDI-S. However,
continuous delivery of the first three doses of albuterol via SVN in the first hour after ED arrival helps to ensure
compliance with national treatment guidelines. In addition, delivery via SVN also facilitates simultaneous
administration of albuterol and ipratropium. Thus, many ED clinicians choose to treat moderately to severely ill
patients with albuterol delivered via SVN. (See 'Nebulizer versus inhaler' below and 'Continuous delivery' below.)
Patients who have received three doses of intermittent therapy and require additional albuterol therapy may be
treated intermittently every 30 to 45 minutes or may be switched to continuous therapy. (See 'Inhaled short-
acting beta agonists' below and 'Ipratropium bromide' below.)
Administration of systemic glucocorticoids soon after arrival in the ED or after the first inhalation therapy is
initiated (table 2). (See 'Systemic glucocorticoids' below.)
Administration of intravenous magnesium sulfate (75 mg/kg, maximum 2.5 g administered over 20 minutes) if
there is clinical deterioration despite treatment with beta agonists, ipratropium bromide, and systemic
glucocorticoids. (See'Magnesium sulfate' below.)
Severe exacerbation For children with severe asthma exacerbation (PIS 12, (table 1)), we suggest the following
approach (algorithm 2):
Administration of supplemental oxygen if oxygen saturation is 92 percent in room air. (See 'Oxygen
therapy' above.)
Albuterol nebulization (0.15 mg/kg, maximum 5 mg) combined with ipratropium bromide (250 microgram/dose if
<20 kg; 500 microgram/dose if >20 kg), every 20 to 30 minutes for three doses or continuously.
Patients who have received three doses of albuterol in the first hour after ED arrival and require additional
albuterol therapy may be treated intermittently every 30 to 45 minutes or may be switched to continuous therapy.
Children with poor inspiratory flow or children who cannot cooperate with nebulized therapy can be treated with
epinephrine or terbutaline (0.01 mL/kg of a 1 mg/mL solution; maximum dose of 0.4 mg or 0.4 mL) administered
intramuscularly or subcutaneously instead of inhaled albuterol and ipratropium. (See 'Inhaled short-acting beta
agonists' below and 'Ipratropium bromide' below and 'Parenteral beta agonists' below.)
Subsequent management depends upon response to initial therapy:
For patients who improve after the initial treatment, the approach is as described above for moderate
exacerbations. (See 'Moderate exacerbation' above.)
For patients with a poor response to initial treatment, we recommend:
Administration of intravenous methylprednisolone (1 to 2 mg/kg, maximum 125 mg). (See 'Systemic
glucocorticoids' below.)
Administration of intravenous magnesium sulfate (75 mg/kg, maximum 2.5 g administered over 20
minutes). (See 'Magnesium sulfate' below.)
For patients who do not respond to these interventions, administration of intravenous terbutaline may be indicated:
bolus with 10 microgram/kg over ten minutes, then 0.3 to 0.5 microgram/kg per minute; infusion may be increased by
0.5microgram/kg per minute every 30 minutes to a maximum of 5 microgram/kg minute. (See 'Parenteral beta
agonists' below.)
PHARMACOTHERAPY The two primary agents used in the treatment of acute asthma exacerbations are inhaled
beta agonists and systemic glucocorticoids. Additional agents are used as needed depending upon the severity of the
exacerbation.
Inhaled short-acting beta agonists Inhaled, short-acting, selective beta-2 adrenergic agonists (beta agonists or
SABA) are the mainstay of emergent treatment of acute asthma exacerbations [8-11]. Albuterol is the most widely
used SABA in the acute setting.
Inhaled beta agonists are administered by intermittent nebulization, continuous nebulization, or metered-dose inhaler
with a spacer (MDI-S, preferably a valved holding chamber). These delivery systems are discussed in detail
separately. (See"Use of medication nebulizers in children" and "The use of inhaler devices in children".)
Nebulizer versus inhaler Clinicians may use either small volume nebulizers (SVNs) or MDI-S when administering
inhaled beta agonists intermittently. These methods appear to be equally effective for children of all ages and with a
wide range of illness severity. Thus, the choice of one over the other mainly depends upon the frequency of dosing
required. (See 'Moderate exacerbation' above and 'Continuous delivery' below.)
Clinical trials and meta-analyses indicate that the administration of beta agonists via MDI-S (4 to 12 puffs) is at least
as effective, and possibly superior to, delivery of medication by SVN in reversing bronchospasm in infants and
children [1,12-14]. (See "The use of inhaler devices in children", section on 'Pressurized MDI or nebulizer?'.)
Advantages of SVN delivery compared with MDI-S include the ability to simultaneously deliver humidified oxygen
and ipratropium bromide and to passively administer drug therapy to a child in respiratory distress. However, when
using SVNs, up to 90 percent of drug remains in the machine or is lost to the atmosphere [15]. In addition, the
portability of SVNs is limited by the need for an external power source. (See "The use of inhaler devices in children",
section on 'Spacers and holding chambers'.)
Continuous delivery Studies comparing continuous versus intermittent nebulized delivery of beta agonists have
found similar outcomes and side effect profiles with both methods [8,9,16-18]. We suggest continuous therapy over
intermittently nebulized or MDI-S therapy for children with moderate to severe exacerbations. (See "Use of medication
nebulizers in children", section on 'Continuous nebulization'.)
Continuous nebulizer therapy is less labor intensive than intermittent nebulizer therapy, resulting in reduced
respiratory therapy costs. In addition, it ensures that the goal of three treatments within the first hour of care for
moderately ill children is met. However, young children may not tolerate wearing a facemask for long periods of time.
(See 'Moderate exacerbation' above and "Delivery of inhaled medication in children", section on 'Patient technique,
acceptance, and preference'.)
Levalbuterol Racemic albuterol (RA) is an equal mixture of two mirror-imaged enantiomers: the active R-albuterol
and S-albuterol. Levalbuterol (LA), on the other hand, is pure R-albuterol. Data from animal studies and in vitro studies
with human cells suggest that S-albuterol may be a weak bronchoconstrictor [19-26]. Thus, in theory, pure active R-
albuterol could be more effective than RA because there is no bronchoconstricting effect from the S-isomer. However,
studies of LA for acute asthma in children have had conflicting results. In addition to its lack of proven superiority, LA
is substantially more expensive than RA. Thus, we suggest RA rather than LA as the drug of choice for children with
acute asthma exacerbations, except in patients with a known history of adverse affects from albuterol. Use of LA is
discussed in greater detail separately. (See "Beta agonists in asthma: Acute administration and prophylactic use",
section on 'Levalbuterol'.)
In the earliest trial, 547 children with acute asthma who were treated in the emergency department (ED) were
randomly assigned to treatment with 1.25 mg LA or 2.5 mg RA every 20 minutes for a maximum of six doses [27]. The
hospitalization rate was higher among children who received RA (45 versus 36 percent). Three subsequent studies
comparing RA with LA in the ED treatment of children with acute asthma found no differences in outcome measures
(changes from baseline clinical asthma score, changes in forced expiratory volume in one second [FEV
1
], number of
treatments, length of ED care, rate of hospitalization) [28-30]. It is worth noting that the baseline admission rates in
these three studies [28-30] were substantially lower than in the first study [27].
Dosing and administration The doses of medications commonly used in the management of acute asthma
exacerbations in children are listed in the table (table 2).
Albuterol via MDI-S Optimal dosing for albuterol administered by MDI-S is not well established. The 2007 National
Asthma Education and Prevention Program (NAEPP) guidelines state that "equivalent bronchodilation can be
achieved either by high doses (4 to 12 puffs) of a short-acting beta agonist by MDI-S with a valved holding chamber or
by nebulizer"; they suggest a dose of four to eight puffs [1].
One strategy is to administer one-quarter to one-third puff/kg (22.5 to 30 microgram/kg) with a maximum of eight puffs
(720 microgram). Thus, proportionately greater doses are provided for young children weighing less than 20 to 30 kg
(44 to 66 pounds), who are the least efficient users.
Another strategy is to use a dosing schedule, stratified by weight, as with continuous albuterol nebulization:
For children who weigh 5 to 10 kg, the dose is four puffs
For children who weigh 10 to 20 kg, the dose is six puffs
For children who weigh >20 kg, the dose is eight puffs
The dose can be repeated every 20 to 30 minutes for three doses, then every one to four hours as needed.
To maximize drug delivery, a spacer (preferably a valved holding chamber [VHC]) should be employed by all patients,
and infants and young children should use a spacer with a facemask, low dead space, and a low resistance valve
(picture 1). Mouthpieces are preferable to facemasks for older children to avoid nasal filtering of drug, which may
reduce lung deposition. (See "The use of inhaler devices in children", section on 'Spacer devices'.)
Intermittent albuterol nebulization The standard dose for nebulized albuterol is 0.15 mg/kg (minimum 2.5 mg;
maximum 5 mg) (table 2) [1,31]. Nebulized albuterol can be administered every 20 to 30 minutes for three doses [1].
Beyond that, frequency of therapy may be limited by side effects, such as tachycardia, hypertension, or tremors.
Patients who have shown little or no improvement after three doses and who are not experiencing significant adverse
effects may be treated every 30 to 45 minutes or switched to continuous therapy.
Drug delivery is maximized by having a total solution volume of 3 to 4 mL and an oxygen flow rate of 6 to 8 L/min [32-
35], tapping the sides of the reservoir to renebulize droplets, and having older children use a mouthpiece to avoid
nasal deposition of drug (picture 1).
Continuous albuterol nebulization The optimal dose for continuous albuterol nebulization therapy has not been
determined. One dosing schedule, stratified by weight, is as follows:
For children who weigh 5 to 10 kg, the dose is 7.5 mg/hour
For children who weigh 10 to 20 kg, the dose is 11.25 mg/hour
For children who weigh >20 kg, the dose is 15 mg/hour
Glucocorticoids The antiinflammatory action of glucocorticoids effectively reduces the airway edema and
secretions associated with acute asthma exacerbations.
Systemic glucocorticoids Systemic glucocorticoids are indicated for most children who present to the ED with an
acute asthma exacerbation, and their effects may be noted within two to four hours of administration [2,36]. Systemic
glucocorticoids are not indicated in children with mild exacerbations who have not received beta-agonist therapy within
a few hours of presenting for medical care and who respond promptly to a single albuterol treatment. When indicated,
we recommend administering systemic glucocorticoids as soon as possible after arrival in the ED. Oral administration
is suitable for most patients. The dosing of systemic glucocorticoids is reviewed in the table (table 2).
A study examined outcomes before and after initiation of a medical directive that allowed triage nurse-initiated
glucocorticoids before clinician assessment in 644 consecutive children presenting with a moderate to severe asthma
exacerbation [37]. Nursing initiation of glucocorticoids was associated with a reduced likelihood of admission (odds
ratio [OR], 0.56; 95% CI, 0.36-0.87), as well as significantly decreased times to clinical improvement and discharge.
The NAEPP guidelines suggest that oral administration of glucocorticoids is preferred to intravenous administration
because oral administration is less invasive and the effects are equivalent [1]. Intramuscular administration of
glucocorticoids (eg, dexamethasone) may be warranted in patients who vomit orally-administered glucocorticoids, yet
do not require an intravenous line for other purposes [38-40].
Orally-administered prednisone or dexamethasone are each a reasonable choice for ED therapy. A meta-analysis
comparing a five-day course of oral prednisolone or prednisone with dexamethasone given as a single intramuscular
dose or one to two daily oral doses for asthma exacerbations managed in the ED found that the treatments were
equivalent with regard to rate of relapse, defined as an unplanned clinic visit, return ED visit, or unplanned
hospitalization related to the initial asthma exacerbation [41]. Lower rates of vomiting, both in the ED and at home,
were seen in the groups treated with dexamethasone via either route of administration compared
with prednisone/prednisolone. However, newer and more palatable prednisone/prednisolone liquid formulations and
oral dissolving tablets are far better tolerated with less frequent episodes of emesis compared with older prednisone
formulations.
It is not necessary to deliver glucocorticoids via the intravenous route, even among the subset of patients being
hospitalized. However, for severely ill patients, intravenous access should be established and
intravenous methylprednisolone may be administered (table 2).
The benefit of early administration (within one hour) of systemic glucocorticoids versus placebo in patients presenting
to the ED with acute asthma exacerbation was evaluated in a meta-analysis of 12 trials involving 863 patients [42].
The following results were reported:
Early administration of systemic glucocorticoids reduced admission rates (pooled OR 0.40, 95% CI 0.21-0.78);
eight patients (95% CI 5-21) would need to be treated to prevent one admission.
The benefit was more pronounced in those not receiving systemic glucocorticoids before ED presentation (OR
0.37, 95% CI 0.19-0.7) and in those with more severe asthma (OR 0.35, 95% CI 0.21-0.59).
Oral glucocorticoids were effective in reducing hospital admission (OR 0.24, 95% CI 0.11-0.53) compared with
placebo in the three trials included in the meta-analysis that evaluated oral glucocorticoids in children with an
acute asthma exacerbation.
Inhaled glucocorticoids The use of inhaled glucocorticoids to treat children with acute asthma is an area of
ongoing clinical research. Studies comparing the use of oral with inhaled glucocorticoids in the ED management of
children with acute asthma have thus far had mixed results. Until more conclusive data are available, we do not
suggest the routine use of inhaled glucocorticoids in addition to, or instead of, systemic glucocorticoids in the
management of acute asthma exacerbation in children.
The following studies are illustrative:
Some studies have found benefits of inhaled glucocorticoids compared with oral glucocorticoids (eg, earlier
discharge from the ED, less vomiting, decreased relapse rate, improved clinical parameters, improved
pulmonary function) [43,44].
Other studies have found oral glucocorticoids and inhaled glucocorticoids to have similar outcomes [45-47].
One study found improved pulmonary function and a lower relapse rate with oral prednisone compared with
inhaled fluticasone [48].
One randomized trial found no additional benefit to adding nebulized budesonide to standard therapy (systemic
glucocorticoids, and inhaled albuterol and ipratropium) early in the course of treatment [49].
Ipratropium bromide Ipratropium bromide is an anticholinergic agent that provides bronchodilation through
smooth muscle relaxation [50]. It is inexpensive and safe.
We recommend that children with moderate to severe asthma exacerbations be treated with ipratropium bromide. We
prefer the nebulized form (250 micrograms per dose for children who weigh <20 kg; 500 micrograms per dose for
children who weigh >20 kg). We administer ipratropium bromide with each of the first three albuterol treatments [51].
Alternatively, ipratropium may be administered with the second and third treatments [52].
In randomized trials, systematic reviews, and meta-analyses [51-55], multiple doses of inhaled ipratropium combined
with inhaled beta agonists have been shown to reduce hospital admissions and improve lung function in children with
severe asthma exacerbations. In contrast, ipratropium has not been shown to reduce the length of hospital stay or to
prevent admission to the intensive care unit (ICU) [56,57].
A systematic review of 20 randomized trials comparing combined inhaled beta 2-agonists and anticholinergic agents
(atropine sulfate and ipratropium bromide) with inhaled beta agonists alone found the following results [55]:
Combination therapy reduced the risk of hospitalization (relative risk [RR] 0.73; 95% CI 0.63-0.85, 15 studies,
2497 children); 16 children (95% CI 12-29) with an asthma exacerbation of any severity would need to be treated
with combination therapy rather than inhaled beta agonists alone to avoid one hospital admission.
The incidence of nausea and tremor was lower in the combination therapy group, but there was no significant
difference in the rate of vomiting.
Ipratropium can be administered via SVN or MDI-S. If administered by MDI-S, the NAEPP guidelines recommend a
dose of four to eight puffs (each puff is 18 micrograms) [1]. The NAEPP guidelines also comment that the MDI dose is
low and has not been studied in asthma exacerbations. The MDI formulation that contains both ipratropium
and albuterol should not be administered to highly sensitive patients with allergy to peanut or soy because it contains
soy lecithin, which may precipitate an allergic reaction (the MDI that contains ipratropium alone no longer contains soy
lecithin). (See "Management of food allergy: Avoidance", section on 'Soy lecithin'.)
Magnesium sulfate There is accumulating evidence that intravenous magnesium sulfate benefits adults and
children with severe asthma [58-63]. Magnesium is inexpensive, has minimal adverse effects at the doses indicated,
and is widely available. The NAEPP guidelines suggest 25 to 75 mg/kg (maximum 2 grams) for severe exacerbations
unresponsive to initial treatments after one hour and as add-on for life-threatening exacerbations [1]. We suggest
using magnesium sulfate in children with severe asthma exacerbations and in children with moderate asthma
exacerbations who have clinical deterioration despite treatment with beta agonists, ipratropium bromide, and systemic
glucocorticoids. Given its relative safety and the critical importance of early effective treatment, in our practice we use
a dose of 50 mg/kg (maximum 2.5 g) given intravenously and administered over 20 minutes. A fluid bolus may be
administered to prevent clinically significant hypotension, a rare side effect of magnesium infusion. Magnesium
infusion is relatively contraindicated in renal failure.
The use of magnesium sulfate in the ED setting for treatment of children with asthma has been evaluated in several
small studies. Four of the five prospective, randomized controlled trials of intravenous magnesium sulfate (25 to
40 mg/kg) in children demonstrated benefit (improved pulmonary function or clinical asthma scores) in children who
had failed to respond to conventional therapy with albuterol and glucocorticoids [61,62,64,65]. A fifth study found no
significant effect of magnesium sulfate (75 mg/kg) on Pulmonary Index Score (PIS), admission rate, or time to
discharge when administered as a component of initial therapy [66]. Serious adverse effects (eg, hypotension) were
not noted in any of the studies.
A meta-analysis of these studies found that magnesium sulfate was effective in preventing hospitalization in children
with moderate to severe acute asthma when added to bronchodilators and glucocorticoids (absolute risk reduction
0.26, 95% CI 0.12-0.39) [67]. Four children would need to be treated to avoid one hospitalization (95% CI 3-8).
Another systematic review and meta-analysis assessed the use of magnesium among 182 children unresponsive to
beta agonists in five separate studies [68]. The use of magnesium was associated with significant benefits in
respiratory function tests and resulted in fewer hospitalizations.
Parenteral beta agonists Subcutaneous and intramuscular beta agonists (eg, epinephrine, terbutaline) are
reserved for children with a severe asthma exacerbation who have poor inspiratory flow or who cannot cooperate with
nebulized therapy. Additionally, intravenous terbutaline, which probably has fewer adverse effects than intravenous
epinephrine, can be used in children with a severe asthma exacerbation who have not responded to initial therapy.
Subcutaneous or intramuscular epinephrine or terbutaline The rapid subcutaneous or intramuscular
administration of beta agonists may be superior to inhaled beta agonists for children with severe exacerbations and
poor inspiratory flow or anxious young children who are uncooperative with or have suboptimal response to initial
aerosolized therapy. The intramuscular route may provide for more rapid drug absorption, although direct
comparisons are lacking. Typically, subcutaneous or intramuscular therapy is given to a severely ill patient who is
aerating poorly within minutes of arrival, concurrent with starting albuterol therapy and obtaining intravenous access.
The dose of subcutaneous or intramuscular terbutaline for bronchodilation is 0.01 mg/kg per dose (0.01 mL/kg of a
1 mg/mL solution) with a maximum dose of 0.4 mg (0.4 mL). The dose of subcutaneous or intramuscular epinephrine
for bronchodilation is 0.01 mg/kg (0.01 mL/kg of 1:1000 solution (1 mg/mL)), with a maximum dose of 0.4 mL (0.4 mg).
The dose may be repeated every 20 minutes for three doses, although most patients are switched to an intravenous
medication (eg, magnesium sulfate, terbutaline) if they do not respond after the second dose of subcutaneous or
intramuscular terbutaline or epinephrine. The dosing interval may be decreased to 5 to 10 minutes for children who
continue with severe respiratory distress; autoinjectable epinephrine may be used for this purpose to avoid a delay in
drawing up the medication. (See 'Magnesium sulfate' above and 'Intravenous terbutaline' below.)
Intravenous terbutaline Severely ill patients who are poorly responsive to conventional therapy may be treated
with a combination of intravenous beta agonists and inhaled beta agonists, although additional studies are needed to
clarify the role of intravenous beta agonists. The possible benefit needs to be weighed against increased side effects
associated with this therapy, including dysrhythmias, hypertension, and myocardial ischemia. There is no role for
using intravenous beta agonists as initial therapy, even for severely ill children.
A systematic review of studies published through September 2012 found only two randomized trials that met inclusion
criteria [69-71]. Limited evidence from these two trials suggests that there is shorter recovery time and improved PISs
with the addition of intravenous beta agonists in children poorly responsive to conventional interventions (including
inhaled beta agonists and ipratropium, systemic glucocorticoids, and magnesium sulfate).
Dosing for intravenous terbutaline in the ED setting is as follows: 10 microgram/kg bolus over 10 minutes, followed by
0.3 to 0.5 microgram/kg per minute; every 30 minutes the infusion may be increased by 0.5 microgram/kg per minute
to a maximum of 3 microgram/kg per minute (higher doses are sometimes used in the ICU setting). (See "Acute
severe asthma exacerbations in children: Intensive care unit management", section on 'Pharmacotherapy'.)
Nonstandard therapies There are insufficient data to support the routine administration of heliox, ketamine, or
leukotriene receptor antagonists (LTRAs) in the treatment of children with acute asthma.
Heliox In theory, a mixture of helium and oxygen may enhance beta agonist delivery because the lower gas
density should result in decreased flow resistance. The 2007 NAEPP guidelines suggest administration of beta
agonists with heliox in patients with life-threatening exacerbations or who are not responding to conventional therapy
[1]. However, the use of heliox should not delay intubation once it is considered necessary. (See "Physiology and
clinical use of heliox", section on 'Use in children'.)
The benefits of continuous beta agonist administration delivery by heliox compared with oxygen were evaluated in a
controlled trial in 30 children (2 to 18 years) with moderate to severe asthma (PIS 8) (table 1) [72]. After initial
treatment withalbuterol inhalation and prednisone or prednisolone, the patients were randomly assigned to receive
continuous albuterol nebulization delivered by heliox or oxygen. At 240 minutes, patients in the heliox group had
greater decrease in PIS score from baseline (decrease of 7 versus 3 points). In addition, more patients in the heliox
group were discharged from the hospital in less than 12 hours (73 versus 33 percent).
Ketamine Due to its bronchodilating properties, the dissociative agent ketamine is the drug of choice to provide
sedation and analgesia before intubating a child with asthma. Although several small case series of nonintubated
children treated with ketamine suggest that ketamine improves acute asthma [73,74], the one randomized trial found
that ketamine was no better than standard therapy in nonintubated children with severe acute asthma [75,76].
(See "Acute severe asthma exacerbations in children: Intensive care unit management", section on 'Sedation and
paralysis'.)
Leukotriene receptor antagonists The data do not support the routine use of LTRA therapy to treat children with
acute asthma exacerbations requiring urgent or emergent care [77]. LTRA add-on therapy in acute asthma has shown
promise in adults [78,79]. However, it does not appear to provide additional benefit in children when added to standard
therapy for acute asthma [80]. (See "Treatment of acute exacerbations of asthma in adults", section on 'Leukotriene
receptor antagonists'.)
A randomized trial of 117 children aged 5 to 15 years treated in the ED found no difference in the Modified Pulmonary
Index Score (MPIS) between those treated with a single age-appropriate dose of montelukast versus placebo [80].
Intravenous montelukast was not effective in improving FEV
1
in a randomized trial of children with acute asthma [81].
DISPOSITION The decision regarding disposition (eg, discharge to home, continued observation, or
hospitalization) is based upon both clinical and social factors.
Discharge to home Children who have marked improvement in clinical parameters within the first one to two hours
of therapy may be discharged home [1]. Marked improvement is manifested by diminished or absent wheezing and
retracting and increased aeration that is sustained at least 60 minutes after the most recent albuterol dose.
Discharge meds All patients seen for an acute asthma exacerbation should have an inhaled short-acting beta
agonist (SABA) available for treatment of symptoms [1]. We suggest treatment with a SABA every four hours during
waking hours and up to every four hours as needed during sleep for the first three days after an emergency
department (ED) visit for an asthma exacerbation. After that, albuterol dosing should be weaned as tolerated, with the
goal of discontinuing by day 5 to 7. (See "Asthma in children younger than 12 years: Rescue treatment for acute
symptoms", section on 'Short-acting beta agonists'.)
We treat children with a short course of oral glucocorticoids if they received a dose of systemic glucocorticoids in the
ED. A three to five day course is sufficient for most children, although a course up to 10 days may be indicated in
some children (eg, those who have had more than one exacerbation requiring oral glucocorticoids in the previous two
months or those who are still symptomatic after a five day course). Greater than 10 days may be necessary for
patients whose control regimen includes oral glucocorticoids. Glucocorticoids that are administered for less than 10
days do not require a taper at discontinuation [82].
Whether inhaled glucocorticoids offer any short-term benefits in addition to inhaled albuterol and oral glucocorticoids
when started in the ED or at the time of discharge from the ED in patients who were not already receiving inhaled
glucocorticoids as controller therapy is a question that remains unanswered [83,84]. However, patients may be started
on an inhaled glucocorticoid in the ED if controller therapy is indicated, to ensure that institution of this therapy is not
delayed or forgotten [85]. (See "Asthma in children younger than 12 years: Treatment of persistent asthma with
controller medications".)
Benefits were not seen with leukotriene receptor antagonists (LTRAs) as monotherapy in children discharged from the
ED after treatment for acute asthma was successful. A five day course of montelukast was not as effective as a similar
course of prednisolone in a randomized trial of 130 children with mild to moderate acute asthma exacerbations who
were stabilized with prednisolone in the ED [86]. Treatment failure occurred in 8 percent of children treated with
prednisolone compared with 22 percent treated with montelukast.
Discharge education Prior to discharge from the ED, it is recommended that the following are reviewed with
patients and their parents/caregivers [1]:
Signs and symptoms necessitating a return visit to the ED including worsening shortness of breath, difficulty
speaking a complete sentence, or increased work of breathing.
The need to follow-up with their primary care provider or asthma specialist within one week of the ED visit.
Discharge medications, with respect to purpose, side effects, and proper technique for administration.
(See "Asthma in children younger than 12 years: Treatment of persistent asthma with controller
medications" and "Asthma in children younger than 12 years: Rescue treatment for acute symptoms" and "The
use of inhaler devices in children", section on 'Spacer devices' and "The use of inhaler devices in children",
section on 'Valved-holding chambers'.)
A written asthma action plan (form 1A-B). (See "What do patients need to know about their asthma?".)
Risk factors for asthma. (See "Risk factors for asthma".)
Prevention of acute exacerbations. (See "Trigger control to enhance asthma management" and "Allergen
avoidance in the treatment of asthma and allergic rhinitis".)
Continued treatment and observation Children with some, but incomplete improvement within the first two hours
of therapy require continued observation. Incomplete response is manifest by modest, but insufficient benefits in
degree of wheezing, retracting, and aeration.
During continued observation, patients with partial improvement should continue to receive albuterol nebulizations
every 30 to 45 minutes (or continuously) for another one to two hours, after which a decision regarding hospitalization
or discharge home is made.
Hospitalization Patients who were moderately to severely ill on arrival and who have little improvement after initial
therapy with beta agonists and systemic glucocorticoids require hospitalization. This includes patients who continue to
have significant wheezing and retracting, poor aeration, or altered mental status, such as drowsiness or agitation.
Additional factors that suggest a need for hospitalization include [1]:
Beta-agonist therapy more often than four hours; patients who require treatment more often than every two
hours may need to be admitted to an intensive care unit (ICU)
Requirement for supplemental oxygen/low oxygen saturation on pulse oximetry an hour or more after
commencement of initial therapy
A history of rapid progression of severity in past exacerbations
Poor adherence with outpatient medication regimen
Recent treatment with systemic glucocorticoids (includes current treatment with oral glucocorticoids at the time
of presentation) or beta agonist overuse
Inadequate access to medical care, including lack of transportation back to the hospital if deterioration occurs
Poor social support system at home, with inability of the caregiver(s) to provide medical care and supervision at
home
A history of severe exacerbations, including a prior need for ICU management with or without invasive or noninvasive
ventilation, even in the setting of mild baseline asthma, suggests the patient may require a greater level of care in the
hospital (ie, admission to the ICU) [87]. (See "Acute severe asthma exacerbations in children: Intensive care unit
management", section on 'Risk factors'.)
Inpatient therapy for acute asthma exacerbations is discussed separately. (See "Acute asthma exacerbations in
children: Inpatient management" and "Acute severe asthma exacerbations in children: Intensive care unit
management".)
Follow-up Patients discharged from the ED should follow-up with their primary care provider or asthma specialist
within one week of the ED visit [1]. At the follow-up, visit the primary care provider can review the child's asthma
control, asthma care plan, and alter controller therapy as indicated. (See "Asthma in children younger than 12 years:
Treatment of persistent asthma with controller medications".)
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, "The Basics" and
"Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5
th
to 6
th
grade reading
level, and they answer the four or five key questions a patient might have about a given condition. These articles are
best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics
patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10
th
to
12
th
grade reading level and are best for patients who want in-depth information and are comfortable with some
medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics
to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info"
and the keyword(s) of interest.)
Basics topics (see "Patient information: How to use your childs dry powder inhaler (The Basics)" and "Patient
information: Asthma in children (The Basics)" and "Patient information: How to use your childs metered dose
inhaler (The Basics)")
Beyond the Basics topics (see "Patient information: Asthma inhaler techniques in children (Beyond the
Basics)" and "Patient information: Asthma treatment in children (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
The immediate goals of treatment of an acute asthma exacerbation include rapid reversal of airflow obstruction
and correction of severe hypercapnia or hypoxemia, if present. (See 'Goals' above.)
Inhaled, short-acting, selective beta-2 adrenergic agonists (beta agonists or SABA) are the mainstay of
management of acute asthma exacerbations (table 2). Systemic glucocorticoids are added if the signs and
symptoms of airway obstruction fail to improve after the first treatment with inhaled beta agonists. (See 'General
approach' above and "Asthma in children younger than 12 years: Rescue treatment for acute symptoms", section
on 'Short-acting beta agonists'.)
The approach to the child with a mild asthma exacerbation (Pulmonary Index Score [PIS] <7, (table 1)) is as
follows (see 'Mild exacerbation' above):
We recommend administration of a SABA (Grade 1A). Beta agonists may be administered by nebulizer
(0.15 mg/kg; minimum 2.5 mg and maximum 5 mg per dose) or metered-dose inhaler with spacer (MDI-S)
(one-quarter to one-third puff/kg; minimum two puffs and maximum eight puffs per dose). SABAs are
administered every 20 to 30 minutes for one to three doses. (See 'Inhaled short-acting beta
agonists' above.)
For patients who do not improve after one inhalation therapy, we recommend the administration of
systemic glucocorticoids (Grade 1A). Oral agents (eg, dexamethasone, prednisolone, or prednisone) are
preferred. (See 'Systemic glucocorticoids' above.)
The approach to management of a moderate asthma exacerbation (PIS 7 to 11, (table 1)) is summarized in
the algorithm (algorithm 1) and below (see 'Moderate exacerbation' above):
Administration of supplemental oxygen is indicated if oxygen saturation is 92 percent in room air.
(See 'Oxygen therapy' above.)
We recommend inhalation therapy with a SABA (Grade 1A). (See 'Inhaled short-acting beta
agonists' above.)
We recommend that children with asthma exacerbations of moderate severity also
receive ipratropium bromide (Grade 1A). We administer ipratropium bromide with each of the first three
beta agonist nebulizer treatments or continuously; alternatively it may be administered with the second and
third treatments. (See 'Ipratropium bromide' above.)
We recommend administration of systemic glucocorticoids soon after arrival in the emergency department
(ED) or after the first inhalation therapy is initiated (Grade 1A). Oral agents
(eg, dexamethasone, prednisolone, orprednisone) are preferred. (See 'Systemic glucocorticoids' above.)
We suggest the administration of intravenous magnesium sulfate for patients with moderate asthma
exacerbations who have clinical deterioration despite treatment with beta agonist, ipratropium, and
systemic glucocorticoids (Grade 2A). (See 'Magnesium sulfate' above.)
The approach to management of a severe asthma exacerbation (PIS 12, (table 1)) is summarized in the
algorithm (algorithm 2) and below (see 'Severe exacerbation' above):
Administration of supplemental oxygen is indicated if oxygen saturation is 92 percent in room air.
(See 'Oxygen therapy' above.)
We recommend nebulized therapy with a SABA for children with a severe asthma exacerbation (Grade
1A). Subcutaneous or intramuscular administration of a beta agonist (eg, terbutaline, epinephrine) is an
alternative for children with poor inspiratory flow, those who are uncooperative with inhalation
therapy, and/or those who have suboptimal response to initial inhalation therapy. (See 'Inhaled short-acting
beta agonists' above and 'Parenteral beta agonists'above.)
We recommend that children with severe asthma exacerbations also receive ipratropium bromide (Grade
1A). We administer ipratropium bromide with each of the first three beta agonist nebulizer treatments or
continuously; alternatively it may be administered with the second and third treatments. (See 'Ipratropium
bromide' above.)
Management after the first dose of SABA depends upon the response to initial therapy. Patients who
improve after the initial inhalation treatment proceed with treatment as for patients with moderate
exacerbations (algorithm 1).
We recommend administration of systemic glucocorticoids after the first inhalation therapy (Grade 1A).
We administer systemic glucocorticoids intravenously since patients with severe exacerbations are likely to
require additional intravenous medications. (See 'Systemic glucocorticoids' above.)
For patients who have a poor response to initial treatment:
-We suggest administration of intravenous magnesium sulfate (Grade 2A). (See 'Magnesium
sulfate' above.)
-We suggest administration of intravenous terbutaline if there is no response to
intravenous magnesium sulfate (Grade 2B). A bolus of 10 microgram/kg is administered over 10
minutes; this is followed by continuous infusion of 0.3 to 0.5 microgram/kg per minute; the infusion
may be increased by 0.5 microgram/kg per minute every 30 minutes to a maximum of
5 microgram/kg minute. (See 'Parenteral beta agonists' above.)
The disposition of children with acute asthma exacerbation depends upon the response during the first one to
two hours of therapy:
Children who have marked improvement in clinical parameters may be discharged home. All patients seen
for an acute asthma exacerbation should have an inhaled SABA available for treatment of symptoms. We
typically advise treating with a SABA every four hours during waking hours and up to every four hours
during sleep for the first three days after discharge from the ED. We treat children with a short course of
oral glucocorticoids if they received a dose of systemic glucocorticoids in the ED. (See 'Discharge to
home' above.)
Children with some, but incomplete, improvement within the first two hours of therapy require continued
observation and treatment. (See 'Continued treatment and observation' above.)
Patients who have little improvement and/or continued need for supplemental oxygen after initial therapy
with beta agonists and systemic glucocorticoids require hospitalization. (See 'Hospitalization' above
and "Acute asthma exacerbations in children: Inpatient management".)
Patients discharged from the ED should follow-up with their primary care provider or asthma specialist within
one week after the ED visit. (See 'Follow-up' above.)

Pulmonary index score
Score
Respiratory
rate*
Wheezing


Inspiratory/expiratory
ratio
Accessory muscle
use
Oxygen
saturation
0 30 None 2:1 None 99 to 100
1 31 to 45 End expiration 1:1 + 96 to 98
2 46 to 60 Entire expiration 1:2 ++ 93 to 95
3 >60 Inspiration and
expiration
1:3 +++ <93
* For patients age 6: through 20, score 0; 21 to 35, score 1; 36 to 50, score 2; >50, score 3. The total score
ranges from 0 to 15. In general, a score of less than 7 indicates a mild attack, a score of 7 to 11 indicates a
moderately severe attack, and a score of 12 or greater indicates a severe attack. However, the Pulmonary Index
Score may underestimate the degree of illness in an older child.
If no wheezing due to minimal air entry, score 3.

Management of moderate asthma

MDI: metered-dose inhaler; IM: intramuscular.
* Consider IM methylpredisolone or oral dexamethasone if the child vomits prednisone.

Management of severe asthma in children

IM: intramuscular; SC: subcutaneous; IV: intravenous.

Recommended doses of medications to treat children with an acute asthma
exacerbation[1]
Inhaled short-acting bronchodilators (beta2-agonists)
Albuterol (salbutamol) by
nebulizer
0.15 mg/kg per dose (minimum 2.5 mg, maximum 5 mg/dose) every 20 to 30 minutes for three doses,
then 0.15 to 0.3 mg/kg (maximum 10 mg) every 30 minutes to four hours as needed or switch to
continuous therapy.
Continuous albuterol (salbutamol)
by nebulizer
0.5 mg/kg per hour (maximum 20 mg per hour) by large volume nebulizer. Dose may also be
determined based upon body weight as follows:
5 to 10 kg - 7.5 mg per hour
10 to 20 kg - 11.25 mg per hour
>20 kg - 15 mg per hour
Albuterol by MDI with spacer
(VHC)
(90 micrograms/puff)
One-fourth to one-third puff/kg or four to eight puffs every 20 to 30 minutes for three doses, then
every one to four hours as needed (minimum two puffs/dose, maximum eight puffs/dose). Use VHC
spacer; add mask in children less than four years.
Levalbuterol (levosalbutamol) One-half the recommended dose for racemic albuterol.
Inhaled bronchodilator (anticholinergic)
Ipratropium bromide nebulizer
solution (250 micrograms/mL)
<20 kg - 250 mcg/dose
20 kg - 500 mcg/dose
Every 20 minutes for three doses, then as needed. May combine with albuterol for intermittent or
continuous nebulizer treatment.
Ipratropium bromide MDI with
spacer (18 micrograms/puff)
Four to eight puffs every 20 minutes as needed for up to three hours. Use VHC spacer; add mask in
children less than four years. May give as combined MDI (18 micrograms ipratropium with 90
micrograms albuterol per puff).
Systemic glucocorticoids
Prednisone or prednisolone* 1 to 2 mg/kg (maximum 60 mg/day) by mouth for the first dose, and then 0.5 to 1 mg/kg twice daily
for subsequent doses starting the following day; a 3 to 10 day course is generally given.
Methylprednisolone 1 to 2 mg/kg (maximum 125 mg/day) IV
Dexamethasone 0.6 mg/kg (maximum 16 mg/day) by mouth, IM or IV
Systemic beta2-agonists


Epinephrine 1 mg/mL (also
labeled 1:1000)
0.01 mg/kg IM or SC if no evidence of anaphylaxis (maximum 0.4 mg/dose = 0.4 mL of 1 mg/mL
solution). May be repeated every 10 to 20 minutes for three doses.
Terbutaline (1 mg/mL) 0.01 mg/kg SC or IM (maximum 0.25 mg/dose). May be repeated every 20 minutes for three doses,
then every two to six hours as needed.
May give terbutaline OR epineprhine, but not both.
Other treatment
Magnesium sulfate 25 to 75 mg/kg IV (0.1 to 0.3 mmol/kg) over 20 minutes (up to 2 grams approximately equal to 8
mmol)


MDI: metered-dose inhaler; VHC: valved holding chamber; IV: intravenous; IM: intramuscular; SC: subcutaneous.
* Useful formulations of prednisolone include concentrated oral liquids and orally disintegrating tablets (ODTs). For
detail, refer to Lexicomp drug specific monograph included with UpToDate.
The use of systemic epinephrine or terbutaline is reserved for patients with poor inspiratory flow or who cannot
cooperate with inhaled therapy. Systemic beta2-agonist treatment requires noninvasive cardiopulmonary
monitoring, such as that available in a critical care setting. Orally administered systemic beta2-agonists are not
recommended.
Maximum dose of magnesium sulfate of up to 2.5 grams IV (approximately equal to 10 mmol) may be
considered. Refer to topic. (Scarfone RJ et al. Ann Emerg Med 2000;36:572).

Child asthma action plan


Asthma action plan

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